Skull Fracture Workup

Updated: Sep 27, 2018
  • Author: Nazer H Qureshi, MD; Chief Editor: Brian H Kopell, MD  more...
  • Print

Laboratory Studies

In addition to a complete neurological examination, baseline laboratory analyses, and tetanus toxoid (where appropriate, as in open skull fractures), the diagnostic workup for fractures is radiological.


Imaging Studies

Skull films are suboptimal in revealing basilar skull fractures. Hence, other than a fracture at the vertex that might be missed by CT scan and picked up by a plain film, skull x-ray is of no benefit when a CT scan is obtained. In one study, skull x-ray missed 19.1% of fractures, whereas CT scan missed 11.9%. [28]

In a retrospective review of 21 infants with possible skull fracture after birth trauma, skull films at the birth hospital were found to be unreliable for fracture in 23% of cases. Seven of nine infants with accidental falls had fracture on computed tomography scan. Only three infants required neurosurgical intervention, all after severe birth trauma associated with instrumentation. [29]

CT scan is the criterion standard modality for aiding in the diagnosis of skull fractures. [4, 5] Thinly sliced bone windows of up to 1-1.5 mm thick, with sagittal reconstruction, are useful in assessing injuries. Helical CT scan is helpful in occipital condylar fractures, but 3-dimensional reconstruction usually is not necessary. [7]

CT scan for skull fractures was found to have a  sensitivity of 85.4% and a specificity of 100% in one study. [30]  In another study, of children with skull fractures suspected of abusive head trauma, CT with 3-dimensional reconstruction was found to be 97% sensitive and 94% specific. [6]

MRI or magnetic resonance angiography is of ancillary value for suspected ligamentous and vascular injuries. Bony injuries are far better visualized using CT scan.



Other Tests

Bleeding from the ear or nose in cases of suspected CSF leak, when dabbed on a tissue paper, shows a clear ring of wet tissue beyond the blood stain, called a "halo" or "ring" sign. A CSF leak can also be revealed by analyzing the glucose level and by measuring tau-transferrin.